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7.1 Late preterm infant; Non-latching

The 'late preterm' baby

Infants born 34 weeks 0 days to 36 weeks 6 days gestational age are categorised as 'late preterm'.1

Late preterm infants with no significant respiratory problems or other problems of prematurity are often cared for on the postnatal ward, with the temptation to treat them as you would a term baby. Often called 'the great pretenders', these infants may present with subtle immaturity that requires a trained eye to detect, and proactive management to prevent subsequent problems.

Some problems these infants may encounter:

  • respiratory instability and interrupted lung development2,3
    • poor ability to clear normal lung fluid (particularly if delivered by elective, pre-labour caesarean section)
    • increased incidence of apnoea
    • little respiratory reserve
  • temperature instability2
  • less glycogen and brown fat stores available to protect against hypoglycaemia4
  • reduced ability to conjugate and excrete bilirubin, increasing need for phototherapy to treat jaundice2
  • neurological immaturity
    • poor state regulation - may go from hyper-alert to deep sleep without intervening stages
    • easily overstimulated, then exhausted - may fall asleep before full breastfeed taken
  • lower tone
  • reduced immunological competence.2 Very important not to separate baby from mother - avoiding nosocomial infections and ensuring extra breastmilk feedings for the immunological protection this gives
  • poor breastfeeding establishment and breastfeeding-associated rehospitalisation5,6,7
  • higher mortality throughout infancy8
  • higher incidence of mental and physical developmental delay at 24 months9,2

Postpartum care

Initial treatment should be no different from any other infant:

  • Skin-to-skin contact immediately after birth - drying and observations occuring on mother's chest
  • Leave in skin-to-skin contact until after the first breastfeed

    Skin-to-skin care will provide

    • optimal physiological stability
    • temperature stability
    • improved oxygen saturation and gas exchange
    • enhanced immune protection (colonization with mother's normal flora; maternal antibody development targeted to baby's needs)
    • decreased crying
    • increased opportunities to breastfeed
    • improved breastmilk production
    • enhanced maternal-infant bonding
    • longer exclusive and total breastfeeding
    all of which are even more important to be achieved quickly for these infants.
  • Delay all routine procedures (eg. vit K injection, eye prophylaxis, hepatitis B vaccine, weighing) until baby stable, settled and had first breastfeed as these procedures increase crying which depletes metabolic reserves and disrupts breastfeeding behaviours. Most can be carried out while skin-to-skin with mother if hospital routine is not flexible.

Lactation Management

The importance of breastfeeding for a preterm infant is even more significant than for full term infants. Yet it is the very nature of the immaturity of the preterm and late preterm that creates breastfeeding challenges. Poor stamina, low tone, difficulty with latch and suck all contribute. Each infant needs to be assessed on individual needs and abilities and a tailor-made breastfeeding support plan can be established.10,7,11

The mother of the late preterm infant should be instructed to respond immediately to early feeding cues, leaving nappy/diaper changing until after feeding due to baby's low energy reserves. Due to the possibility of poor milk transfer associated with low energy reserves and low tone, encourage mothers to express after every breastfeeding attempt to ensure adequate drainage, or 2-3 hourly, unless baby breastfed vigorously. Small frequent feeds accommodate small stomach capacity and lessen chance of overdistension. A maximum length of 2-3 hours between breastfeeds may need to be set as these babies are sleepier and may not wake for feeds.

Involve experienced lactation support.

A lactation consultant can determine the need for additional lactation support such as:

  • special positioning in view of maturity deficits
  • jaw support while breastfeeding, if hypotonia present
  • breast compression/massage
  • determine whether a lactation aid is indicated, eg. nipple shield after lactogenesis II, or tube-feeding device at breast

Note special attention to:

  • output - both urine and stool
  • weight gain/loss
  • level of jaundice
  • essential early post-discharge follow-up

Don't be complacent

These babies are NOT term babies. They may initially appear to cope well (remember 'the great pretenders'), but exhibit decreasing stamina and ability after several days so need to be watched carefully.

What should I remember?

  • Near-term is not full term even if appearing to be well.
  • Be observant of all aspects of baby's condition and progress.
  • Skin-to-skin is highly significant to enhancing stablization of all body systems.
  • Breastfeeding management which minimises energy usage and protects milk supply.

Self-test quiz

The Non-latching Baby

There are many reasons for a newborn not to latch or latch poorly and breastfeed ineffectively. The following have been associated with sub-optimal breastfeeding behaviors on Day 3 postpartum:

  • condition at birth compromised (trauma, intrapartum drugs, resuscitation required)
  • pacifier/dummy use
  • flat or inverted nipples
  • breastfeeding delayed for up to 48 hours, and
  • primiparous mothers.12

It has been demonstrated that forcing the baby to the breast can abolish the rooting reflex and disturb placement of the tongue. A healthy baby should have the opportunity of showing hunger and optimal reflexes, and attach to its mother's breast by itself.13

Read this Externalshort article that describes the detrimental effects of a hand placed on the back of the baby's head during latching.

Your first responsibility

A newborn who shows no inclination to breastfeed is abnormal until proven otherwise.

The most important concern when a baby is not exhibiting this expected reflex is to rule out infant morbidity. Observe the infant's vital signs and organize a pediatric review if any abnormality is detected. Conditions such as unexpected respiratory distress syndrome, Group B strep infection, sepsis, hypoglycaemia, etc may first present as a baby not exhibiting the normal feeding reflexes. We also know that it could be as a result of intrapartum drugs or the birthing experience, and the baby just needs more time, but don't assume that until you have eliminated the more sinister causes.

Principles of management

The aim of your plan is to:

  1. protect the baby: this not only means to ensure the physical well-being of the infant (nutrition and warmth), but includes protecting the baby from unnecessary supplementation before it is indicated.
  2. protect the lactation: until such time as baby is suckling well

Re-establish skin-to-skin care on mother's chest if this had been interrupted. This baby should have A LOT of time in this position. Encourage the mother to adopt the laid back position of Biological Nurturing to stimulate pre-feeding behaviours.

Avoid stressful events/procedures and handle the baby with care ie. definitely don't hold the infant's head in an attempt to hasten latching.

Encourage the mother to respond immediately to baby's earliest feeding cues and instinctive behaviours.

Trickle small amounts of breastmilk into the corner of the infant's mouth as he lies near the breast.

Workbook Activity 7.1

Complete Activity 7.1 in your workbook.

The Action Plan

From 0 to 24 hours old

  • initiate and maintain skin-to-skin contact with the mother. Utilizing the baby's instinctual reflexes is very important.
  • teach the mother about the early feeding cues, ie. wriggling, bringing hand to mouth, rooting; ensure she knows to facilitate feeding immediately the baby shows these cues
  • continue to observe the baby's vital signs regularly and observe for symptoms of hypoglycemia (blood testing not indicated if asymptomatic). Initiate pediatric review if outside the range of normal.
  • be patient and reassure the mother, providing the baby's condition is satisfactory.
  • hand express breastmilk each time baby tries unsuccessfully to breastfeed. Finger-feed, spoon feed or slowly trickle the tiny volumes into the corner of the baby's mouth from a syringe if the baby is swallowing OK.
  • hand expressing should have commenced within 6 hours of birthing (preferably earlier) and regularly at least 3 hourly thereafter (up to 5 hour break overnight).14 While the baby's condition should not deteriorate due to lack of feeding in this first 24 hours, giving the baby the expressed milk makes common sense.

From 24 to 48 hours old

  • continue in skin-to-skin care
  • continue regular observations of vital signs and for signs of hypoglycemia.
  • attempt to rouse and interest baby in breastfeeding every 3 hours. If unsuccessful ...
  • Feed the baby! Average breastmilk volume taken during the second 24 hours is 5 - 15ml per feed with a 24 hour volume of 84ml. This should be your goal.
    • cup, finger or spoon feed the breastmilk to the baby. Giving more than 2 supplements using a bottle can lead to discontinuation of exclusive, and any, breastfeeding.15
    • continue regular hand expressing or pumping at least 8 times per 24 hours.
    • refer mother and baby to a Lactation Consultant for evaluation.

From 48 to 72 hours old

  • Continue all strategies as above
  • Average volume of breastmilk taken is 400ml (13.5oz) per day, or about 8 feeds of 50ml/feed - or less volume more frequently depending on the volume the mother is able to express each time.

After 72 hours

  • Lactogenesis II should have occurred by now
  • Continue all strategies as above
  • Average daily volume of breastmilk consumed from Day 5 is 700ml (~24oz). Some babies may settle and thrive on less, some may require more.

(The recommended daily volumes are taken from the average volume taken at the breast by the well, full-term baby. Refer to the table in topic 6.2.)

Note: Never underestimate the significance of skin-to-skin contact to trigger instinctive reflexes and enhance recovery.

Does your Unit have a policy on the non-latching baby?

Review the policy. Is it current, using up-to-date research to support the recommendations? If not, form a small group to research the topic then draft a policy that you present to your colleagues (midwifery, nursing and medical). Ensure all staff are familiar with the policy to avoid conflicting information and management strategies.

Breast refusal in the older baby

Babies may be fussy at the breast and refuse to breastfeed for a period of time. Before 12 months of age this is rarely due to the infant choosing to wean.

Determine that it actually is breast refusal. Mothers sometimes misinterpret an older baby's quicker more efficient feeding, or a decreased need for breastmilk when complementary foods are introduced, as breast refusal. During very hot weather baby may not feed during the heat of the day, but will feed well in the evening or during the night. Other reasons may be pain, forceful MER/low supply, flavour changes and sucking confusion.

Management strategies for the older baby

  • Record a comprehensive history, including specifics on breastfeeding behavior and urine and stool output prior to this episode. Record the change in behavior and baby's current output.
  • Do an assessment of the baby including weight, length, head circumference, attainment of appropriate developmental milestones, observation of alertness and general health. If there are signs of delayed growth or ill health, refer the baby to a doctor.
  • Observe a breastfeed, or attempted breastfeed. (Review Topic 5.2 Assessing Breastfeeding)
  • If refusal persists for more than one or two missed feeds

    • the mother should express her milk to maintain her milk supply, and
    • use the expressed milk to feed baby, preferably using a cup. In the absence of donor breastmilk, artificial infant formula will be required if mother's milk volumes are inadequate or baby refuses the breastmilk.
    • a medical review of the baby is indicated if baby won't feed at all.

Detective work is needed!

This is a distressing time for the mother, who may be feeling variously angry, rejected, worried, disappointed and bewildered. Good counseling skills will help you to empathise with the mother and work together through a comprehensive history-taking to find a reason for the baby's behaviour. If you can determine the cause you can then direct your management strategies more effectively.

General guidelines include:

  • patience; avoid trying to force the baby to breastfeed or displaying anxiety or anger during attempts
  • encourage lots of skin-to-skin time in bed together or sharing a bath. Don't expect the baby to breastfeed ... but it just might happen
  • observe the environment - avoid distractions such as other children, toys, television, etc. Choose a dimly lit room and play some relaxation music.
  • attempt breastfeeding when baby is nearly asleep or just beginning to wake up
  • offer the breast instead of pacifier/dummy, and when infant starts thumb sucking
  • suggest baby be cup fed rather than bottle fed when separated from the mother
  • suggest the use of a tube feeding device at the breast if supplements were being given
  • give written instructions and supervise the mother using alternative feeding methods until she feels confident doing it herself.

Workbook Activity 7.2

Complete Activity 7.2 in your workbook.

What should I remember?

  • Protect the baby. Protect the lactation.
  • Be a detective to determine possible cause of non-latch or refusal.
  • Know the protocol to follow for a non-latching infant in the first 24 hrs after birth and for each day until secretory activation.
  • Encourage patience.

Self-test quiz

Give your response

Notes

  1. # Engle WA (2006) A recommendation for the definition of "late preterm" (near-term) and the birth weight-gestational age classification system.
  2. # Baumert M et al. (2011) [Late preterm infants--complications during the early period of adaptation].
  3. # Resch B et al. (2011) Are late preterm infants as susceptible to RSV infection as full term infants?
  4. # AAp Committee on Fetus and Newborn (2011) Postnatal glucose homeostasis in lat preterm and term infants
  5. # Radtke JV (2011) The paradox of breastfeeding-associated morbidity among late preterm infants.
  6. # Vessière-Varigny M et al. (2010) [Breastfeeding in a population of preterm infants: a prospective study in a university-affiliated hospital].
  7. # Cleaveland K (2010) Feeding challenges in the late preterm infant.
  8. # Tomashek KM et al. (2007) Differences in mortality between late-preterm and term singleton infants in the United States, 1995-2002.
  9. # Woythaler MA et al. (2011) Late preterm infants have worse 24-month neurodevelopmental outcomes than term infants.
  10. # Ahmed AH (2010) Role of the pediatric nurse practitioner in promoting breastfeeding for late preterm infants in primary care settings.
  11. # Walker M (2008) Breastfeeding the late preterm infant.
  12. # Dewey K (2003) Guiding Principles for Complementary Feeding of the Breastfed Child
  13. # Widstrom AM et al. (1993) The position of the tongue during rooting reflexes elicited in newborn infants before the first suckle
  14. # Furman L et al. (2002) Correlates of lactation in mothers of very low birth weight infants
  15. # Howard CR et al. (2003) Randomized clinical trial of pacifier use and bottle-feeding or cupfeeding and their effect on breastfeeding